Name Flags Card. Type Description & Constraints Composition 0..* CompositionUvIps International Patient Summary composition Slices for category 1..* CodeableConcept Categorization of Composition Slice: Unordered, Open by value:$this category:pregnancySummaryDocument 1..1 CodeableConcept Categorization of Composition Required Pattern: At least the following coding 1..* Coding Code defined by a terminology system Fixed Value: (complex) system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org code 1..1 code Symbol in syntax defined by the system Fixed Value: 90767-5 section 19..* BackboneElement Sections composing the IPS section:sectionProceduresHx 1..1 BackboneElement IPS History of Procedures Section section:sectionImmunizations 1..1 BackboneElement IPS Immunizations Section section:sectionResults 1..1 BackboneElement IPS Results Section section:sectionVitalSigns 1..1 BackboneElement IPS Vital Signs Section section:sectionPastIllnessHx 1..1 BackboneElement IPS History of Past Illness Section section:sectionPlanOfCare 1..1 BackboneElement IPS Plan of Care Section entry:birthPlan 0..1 Reference(Resource) Optional entry used to represent structured care plans section:sectionSocialHistory 1..1 BackboneElement IPS Social History Section entry:drugUse 0..1 Reference(Drug Use | Observation) Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) entry:smokingTobaccoUseFrequency S 0..1 Reference(Smoking and Tobacco Use Frequency) Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) entry:alcoholUseFrequency S 0..1 Reference(alcohol Use) Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) entry:exercise 0..1 Reference(Exercise | Observation) Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) entry:diet 0..1 Reference(Diet | Observation) Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) entry:toxicExposure 0..1 Reference(Toxic Exposure | Observation) Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) entry:sdohObservations S 0..1 Reference(Homelessness | At risk of domestic violence | Observation) Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) entry:occupationalDataForHealth 0..1 Reference(Employment Status) Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) section:sectionPregnancyHx 1..1 BackboneElement IPS History of Pregnancy Section entry 1..* Reference(Resource) Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. entry:currentPregnancyObservations S 1..* Reference(Observation | Multiple Pregnancy | Gestational Age | Date Of Last Menstral Period) Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. entry:historicalPregnancyObservations S 0..* Reference(Observation | Pregnancy History Observations) Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. section:sectionAdvanceDirectives 1..1 BackboneElement IPS Advance Directives Section entry:advanceDirectivesObservation S 0..* Reference(Advance Directives Observation) Narrative description of the patient's advance directive. section:ChiefComplaint S 1..1 BackboneElement Cheif Complaint code S 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following coding 1..* Coding Code defined by a terminology system Fixed Value: (complex) system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org code 1..1 code Symbol in syntax defined by the system Fixed Value: 10154-3 text 1..1 Narrative Text summary of the section, for human interpretation section:FamilyMedicalHistory S 1..1 BackboneElement Family Medical History code S 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following coding 1..* Coding Code defined by a terminology system Fixed Value: (complex) system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org code 1..1 code Symbol in syntax defined by the system Fixed Value: 10157-6 entry 0..* Reference(Observation) A reference to data that supports this section section:ReviewOfSystems S 1..1 BackboneElement Review of Systems code S 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following coding 1..* Coding Code defined by a terminology system Fixed Value: (complex) system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org code 1..1 code Symbol in syntax defined by the system Fixed Value: 10187-3 section:HistoryOfInfection S 1..1 BackboneElement History of Infection code S 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following coding 1..* Coding Code defined by a terminology system Fixed Value: (complex) system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org code 1..1 code Symbol in syntax defined by the system Fixed Value: 56838-6 entry 0..* Reference(Condition) A reference to data that supports this section section:PhysicalExams S 1..1 BackboneElement Physical Exams code S 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following coding 1..* Coding Code defined by a terminology system Fixed Value: (complex) system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org code 1..1 code Symbol in syntax defined by the system Fixed Value: 29545-1 entry 0..* Reference(Observation) A reference to data that supports this section section:Payors 0..1 BackboneElement Payors code S 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following coding 1..* Coding Code defined by a terminology system Fixed Value: (complex) system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org code 1..1 code Symbol in syntax defined by the system Fixed Value: 48768-6 entry 0..* Reference(Coverage) A reference to data that supports this section section:AntepartumVisitSummaryFlowsheet S 1..1 BackboneElement Antepartum Visit Summary Flowsheet code S 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following coding 1..* Coding Code defined by a terminology system Fixed Value: (complex) system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org code 1..1 code Symbol in syntax defined by the system Fixed Value: 57059-8 entry 0..* Reference(Observation) A reference to data that supports this section section:AntepartumEducation S 1..1 BackboneElement AntepartumEducation code S 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following coding 1..* Coding Code defined by a terminology system Fixed Value: (complex) system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org code 1..1 code Symbol in syntax defined by the system Fixed Value: 34895-3 entry 0..* Reference(Procedure | Pregnancy Education Observation | DocumentReference) A reference to data that supports this section Documentation for this format
Antepartum Summary is a content profile that defines the structure for the aggregation of significant events, diagnoses, and plans of care derived from the visits over the course of an antepartum episode. It is represented in part by Estimated Due Dates and a Visit Summary Flowsheet, in which the aggregated data from the ambulatory office visits is recorded, as well as allergies, advance directives, care plans, and selected histories are provided. The Antepartum Summary represents a summary of the most critical information to an antepartum care provider regarding the status of a patient’s pregnancy.
International Patient Summary composition
International Patient Summary composition. A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.
While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
Version-specific identifier for composition
Version specific identifier for the composition, assigned when each version is created/updated.
While each resource, including the composition itself, has its own version identifier, this is a formal identifier for the logical version of the composition as a whole. It would remain constant if the resources were moved to a new server, and all got new individual resource versions, for example.
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Version-independent identifier for the Composition
A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.
Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
preliminary | final | amended | entered-in-error
The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.
If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.
Need to be able to mark interim, amended, or withdrawn compositions or documents.
This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
The workflow/clinical status of the composition.
interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
Specifies that this composition refers to a Patient Summary (Loinc "60591-5")
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Key metadata element describing the composition, used in searching/filtering.
fhir:CodeableConcept rdfs:subClassOf dt:CD
A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.
This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)).
Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.
High-level kind of a clinical document at a macro level.
.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
Who and/or what the composition is about
Who or what the composition is about. In general a composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). For the IPS the subject is always the patient.
For clinical documents, this is usually the patient.
Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Literal reference, Relative, internal or absolute URL
A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Type the reference refers to (e.g. "Patient")
The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Aa resource (or, for logical models, the URI of the logical model).
Logical reference, when literal reference is not known
An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Plain text narrative that identifies the resource in addition to the resource reference.
This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Describes the clinical encounter or type of care this documentation is associated with.
Provides context for the composition and supports searching.
unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
The composition editing time, when the composition was last logically changed by the author.
The Last Modified Date on the composition may be after the date of the document was attested without being changed.
dateTime is used for tracking, organizing versions and searching. Note that this is the time of *authoring*. When packaged in a document, [Bundle.timestamp](http://hl7.org/fhir/bundle-definitions.html#Bundle.timestamp) is the date of packaging.
DocumentReference.content.attachment.date, DocumentReference.created
Identifies who is responsible for the information in the IPS, not necessarily who typed it in. The type of author(s) contribute to determine the "nature"of the Patient Summary: e.g. a "human-curated" IPS Vs. an "automatically generated" IPS.
Identifies who is responsible for the content.
Official human-readable label for the composition. For this document should be "International Patient Summary" or any equivalent translation
For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
DocumentReference.description, DocumentReference.content.attachment.title
The code specifying the level of confidentiality of the Composition.
The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.
Codes specifying the level of confidentiality of the composition.
A participant who has attested to the accuracy of the composition/document.
Identifies responsibility for the accuracy of the composition content.
Extensions that cannot be ignored even if unrecognized
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
personal | professional | legal | official
The type of attestation the authenticator offers.
Indicates the level of authority of the attestation.
The way in which a person authenticated a composition.
implied by .authenticator/.legalAuthenticator
When the composition was attested by the party.
Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).
./time[type="TS" and isNormalDatatype()]
Who attested the composition in the specified way.
Identifies who has taken on the responsibility for accuracy of the composition content.
./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
Organization which maintains the composition
Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.
This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.
Identifies where to go to find the current version, where to report issues, etc.
.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
Relationships to other compositions/documents
Relationships that this composition has with other compositions or documents that already exist.
A document is a version specific composition.
The type of relationship that this composition has with anther composition or document.
If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.
The type of relationship between documents.
The target composition/document of this relationship.
.target[classCode="DOC", moodCode="EVN"].id
The clinical service(s) being documented
The main activity being described by a IPS is the provision of healthcare over a period of time. In the CDA representation of the IPS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. In the FHIR representation at lest one event should be used to record this information. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the IPS is generated by a GP based on information recorded in his/her EHR-S, then the start value should represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event.
The event needs to be consistent with the type element, though can provide further information if desired.
Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.
Code(s) that apply to the event being documented
This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.
An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.
This list of codes represents the main clinical acts being documented.
The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.
The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.
The provision of healthcare over a period of time this IPS is documenting.
The root of the sections that make up the IPS composition.
A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
exists(f:text) or exists(f:entry) or exists(f:section)
A section can only have an emptyReason if it is empty
not(exists(f:emptyReason) and exists(f:entry))
./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
A code identifying the kind of content contained within the section. This must be consistent with the section title.
The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Provides computable standardized labels to topics within the document.
Classification of a section of a composition/document.
Identifies who is responsible for the information in this section, not necessarily who typed it in.
Who/what the section is about, when it is not about the subject of composition
The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
.subject? (CDA did not differentiate between subject and focus)
Text summary of the section, for human interpretation
A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Document profiles may define what content should be represented in the narrative to ensure clinical safety.
How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
The processing mode that applies to this section.
Specifies the order applied to the items in the section entries.
Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
What order applies to the items in the entry.
.outboundRelationship[typeCode=COMP].sequenceNumber > 1
A reference to data that supports this section
A reference to the actual resource from which the narrative in the section is derived.
If there are no entries in the list, an emptyReason SHOULD be provided.
.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Allows capturing things like "none exist" or "not asked" which can be important for most lists.
A nested sub-section within this section.
Nested sections are primarily used to help human readers navigate to particular portions of the document.
The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary. The actual content could depend on the jurisdiction, it could report: - the currently active medications; - the current and past medications considered relevant by the authoring GP; - the patient prescriptions or dispensations automatically extracted by a regional or a national EHR. In all those cases however medications are documented in the Patient Summary as medication statements. This section requires either an entry indicating the subject is known not to be on any relevant medication; either an entry indicating that no information is available about medications; or entries summarizing the subject's relevant medications.
The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Medication Summary
Concept - reference to a terminology or just text
A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.
Medications relevant for the scope of the patient summary
This list the medications relevant for the scope of the patient summary or it is used to indicate that the subject is known not to be on any relevant medication; either that no information is available about medications.
This section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.
Relevant allergies or intolerances (conditions) for that patient.
It lists the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. This entry shall be used to document that no information about allergies is available, or that no allergies are known .
The IPS problem section lists and describes clinical problems or conditions currently being monitored for the patient.
Clinical problems or conditions currently being monitored for the patient.
It lists and describes clinical problems or conditions currently being monitored for the patient. This entry shall be used to document that no information about problems is available, or that no relevant problems are known.
The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to: 1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section) 2. Therapeutic procedure: e.g. dialysis; 3. Surgical procedure: e.g. appendectomy
Patient past procedures pertinent to the scope of this document.
It lists the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to: 1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section) 2. Therapeutic procedure: e.g. dialysis; 3. Surgical procedure: e.g. appendectomy. This entry shall be used to document that no information about past procedures is available, or that no relevant past procedures are known.
The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section includes the current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.
Patient's immunization status and pertinent history.
It defines the patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. It may contain the entire immunization history that is relevant to the period of time being summarized. This entry shall be used to document that no information about immunizations is available, or that no immunizations are known.
The medical devices section contains narrative text and coded entries describing the patient history of medical device use.
It describes the patient history of medical device use. This entry shall be used to document that no information about medical device use is available, or that no relevant medical device use is known.
This section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results.
Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results.
The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included
Notable vital signs or physical findings.
Notable vital signs or physical findings as: blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included
The History of Past Illness section contains a description of the conditions the patient suffered in the past.
Conditions the patient suffered in the past.
It contains a description of the conditions the patient suffered in the past.
The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments will be specified by future versions of this guide.
Optional entry used to represent disabilities and functional assessments
It describes capabilities of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments will be specified by future versions of this guide.
The plan of care section contains a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.
Optional entry used to represent structured care plans
Dynamic, personalized plan including identified needed healthcare activity, health objectives and healthcare goals, relating to one or more specified health issues in a healthcare process [Source EN ISO 13940]
The social history section contains a description of the person’s Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.)
Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.)
Description of the person’s Health related “lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.)
The history of pregnancy section shall contain information about whether the patient is currently pregnant or not. It may contain addition summarizing information about the outcome of earlier pregnancies.
Current pregnancy status and, optionally, information about the outcome of earlier pregnancies.
It contains information about whether the patient is currently pregnant or not. It may contain addition summarizing information about the outcome of earlier pregnancies.
The advance directives section contains a narrative description of patient's advance directive.
Narrative description of the patient's advance directive.
Contains a narrative description or a Consent entry with information about the patient's advance directive.
Chief complaint records the patient's primary complaint (the patient's own description).
The family history section shall include entries for family history
The review of systems section shall contain a narrative description of the responses the patient gave to a set of routine questions on the functions of each anatomic body system.
The History of Infection section shall contain a narrative description of any infections the patient may have contracted prior to the patient's current condition.
The coded Detailed Physical Examination section shall contain only the required and optional subsections performed.
The Payers section contains data on the patient’s payers, whether a ‘third party’ insurance, self-pay, other payer or guarantor, or some combination. .
This section is a running history of the most important elements noted for a pregnant woman.
The Antepartum Education contains a list of patient education activities that have occured or have been planned to review with the patient.